Shoulder Arthroplasty for Proximal Humerus Fracture

Transcription

1 Arthroplasty in Upper Limb Trauma AADO/HKSSH Conjoint Scientific Meeting 2012 Shoulder Arthroplasty for Proximal Humerus Fracture Dr TSE Lung Fung Department of O&T, Prince of Wales Hospital The Chinese University of Hong Kong

2 Let s start with a case Mr. Lee M/84 Good past health Retired, lives alone ADL independent Right handed

3 The history Slipped and fell while getting off bus 7/6/2008 Landed on out stretched right hand Immediate pain over right upper arm Failed to move injury arm Denied preceding symptoms HI with mild bleeding right forehead

4 At other hospital Admitted to ORT unit X ray showed right # neck of humerus, displaced P/E showed axillary nerve intact, no distal NV deficit, active finger movement Suggested for operation Patient strongly requested for DAMA for geographical reasons

5 2 days later Attended PWH AED 9/6/2008, admitted our unit Chief complaint: Persistent pain right upper arm near shoulder 1st dorsal web space numbness

6 P/E on arrival Significant right shoulder defomity Right shoulder swelling +ve Max tenderness at proximal humerus Decreased ROM of shoulder due to pain Motor at elbow / wrist / fingers intact Decreased light touch sensation distal to wrist Radial pulse not palpable; Doppler signal +ve Distal skin pale, but warm, cap refill normal

7 X rays shoulder / humerus

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9 CT angiogram

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19 Progress EOT done Intra-op findings: 4-part fracture of right proximal humerus Proximal humeral shaft impingement on axillary artery Artery still intact Partial shoulder replacement done Axillary artery released from kinking Right radial pulse revert to normal

20 Post-op X ray

21 Proximal humeral fracture Incidence: 5% Etiology: Fell on out stretched hand High energy trauma 4 major parts: Humeral head superior to anatomical neck Lesser tuberosity Greater tuberosity Shaft of humerus

22 PWH Fracture Pattern Dr LF Tse/ Dr N Tang no >/=81 Age prox shaft distal

23 Stable vs Unstable Stable Impacted fracture Unstable Two-part Three-part Surgical neck + greater / lesser tuberosity Four-part Anatomical neck + tuberosities Fracture dislocation

24 Possible associated injuries Brachial plexus injury (motor + sensory) Axillary artery injury Mechanism: Direct injury by sharp bony fragments / laceration Stretching / Bowstringing due to displaced fragment

25 Posteomedial branch anastomoses with arcuate artery

26 Challenge: Geriatric Patients Osteopenic Bone BMD correlates linearly with bone holding for plates and screws Bone failure vs implant failure Complications: 1. Joint stiffness 2. Non-union 3. Mal-union 4.Osteonecrosis 5. Heterotrophic bone formation

27 Indication for shoulder arthroplasty Three parts or four parts fracture and fracture dislocation on very osteoporotic bone chronic dislocation with impression # of humeral head > 40% articular surface head splitting fracture fail ORIF or conservative treatment old fracture with humeral head resorbed

28 A little history French surgeon Pean inserted platinum and rubber components to replace a shoulder joint destroyed by tuberculosis Neer I, Vitallium Hemiarthroplasty prosthesis which resulted in pain relief and good function compared to previous options.

29 1974- Neer II Prosthesis. Modified Neer I to conform to a glenoid component. Courtesy of Smith & Nephew

30 Implant Mono-block Modular 4 sizes, XS, S, M, L

31 Supine or Beach Chair position Head Stabilization Free the shoudler joint Arm Support

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33 Fluocoscopy Glenohumeral Joint

34 Surgical Approach

35 Deltopectoral Approach Coracoid

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37 Procedure ZIMMER BIGLIANI/ FLATOW THE COMPLETE SHOULDER SOLUTION

38 Procedure ZIMMER BIGLIANI/ FLATOW THE COMPLETE SHOULDER SOLUTION

39 Re-attachment of lesser and greater tuberosities and capsules

40 Post-op Shoulder immobilizer

41 Questions?